Goal-Oriented Action and Learning for Multimorbidity Management in Primary Care (GOAL-MM)

Background: Multimorbidity (MM) represents a critical global health challenge characterized by the coexistence of multiple chronic conditions. MM significantly increases healthcare utilization, reduces patient quality of life, and leads to healthcare costs up to 2.85 times higher than those without MM. The rise of digital health interventions and its impact has created new opportunities for improving MM management in primary and home-based care settings (HBPC). The purpose of GOAL-MM is to strengthen primary care systems by integrating Goal-Oriented Care (GOC) and digital multimorbidity management within Primary Care Practice-Based Research and Learning Network (PBRLN) internationally.

 

Approach: This project, undertaken by investigators from Canada, Norway and Portugal, seeks to advance practice-based research and learning on digital services' impact on care continuity, patient engagement, and primary care efficiency while reducing institutional care dependence. The project uses co-design and co-creation approaches with primary care clinicians and their patients living with MM to adapt and deploy the Multimorbidity Management Health Information System (METHIS) platform across these countries.

 

METHIS enables real-time monitoring by patients and clinicians from electronic medical record, wearable (e.g. heart rate, step counter) and survey (patient reported experience and outcome measures) data. The platform also enables predictive analytics and personalized self-management tools to detect and manage MM decline. METHIS supports both clinical care and research data collection. We use this project to facilitate the development of a Learning Health System that promotes collaborative knowledge exchange and evidence-based decision-making towards GOC.

 

We use will ensure sustainability through comprehensive economic and clinical evaluations examining cost-effectiveness, health system efficiencies, institutional care reduction, patients' health outcomes and satisfaction among primary care clinicians.

Results: The METHIS platform's Portuguese implementation has already demonstrated significant impact through improved care coordination, reduced avoidable hospitalizations and emergency visits, and enhanced mental health outcomes. The Lisbon region pilot demonstrated measurable improvements in patient engagement and care coordination, establishing a foundation for international scaling. The shift toward GOC and integrated, patient-centred models offers a promising approach by focusing on individualized health goals rather than single-disease paradigms.

 

We expect similar findings after adaptation to the Norway and Canadian contexts. Through this project we expect to reach over 150 PBRLN leaders, contribute to the WONCA Global Practice-Based Research Network Initiative and serve as the inaugural multimorbidity priority for this initiative.

 

Implications: This project reimagines primary care through comprehensive digital innovation, employing communication tools and AI-driven risk stratification to detect early signs of multimorbidity-related decline. By enhancing data exchange and connecting patients with primary care teams and community resources, the initiative supports more integrated care planning through novel delivery models.

 

Leveraging PBRLN IT infrastructures, the platform aims to streamline health data flow across different national contexts. The project is specifically designed to minimize workload for clinicians by reducing manual data entry requirements and facilitating communication, while simultaneously creating new opportunities for embedded, practice-based research and learning.